Bosshardt DD, Sculean A, Windisch P, Pjetursson BE, et al.

Effects of enamel matrix

proteins on tissue formation along the roots of human teeth. J Periodont Res
2005;40;15867. (68 Refs)

Purpose: A detailed structural analysis of the newly formed tissue on the roots affected by
periodontitis following the application of EMD.

Materials and Methods: 10 patients (5 females and 5 males; mean age of 50 years) with 12
advanced intrabony periodontal defects around teeth scheduled for extraction were selected.
Full thickness flaps were raised and a notch was placed in the root surface at the apical level
of the calculus present on the root surface. If no calculus was present, the notch was placed
at the base of the periodontal defects. After SRP, EMD was filled in the defects and patients
were advised to rinse with 10 ml of 0.2% CHX solution twice daily postoperatively .2-6
weeks after surgery, teeth were removed and sectioned for observation with light and
transmission electron microscope.

Findings and Conclusions: Postoperative healing was uneventful in all cases with no
adverse tissue reactions such as root resorption or ankylosis.
Light microscopy: Of the 12 defect, 4 revealed the presence of a newly formed mineralized
tissue in the notch area on the root surface. In 2 of these, the new tissue extended apically
over the native cementum. In 2 other defects, a localized thickening of the native cementum
layer was observed at a site that was unrelated to the notch area. In 5 defects, new tissue
formation was evident on scaled root surface at sites unrelated to the notch area. In 6
defects, a mineralized tissue was observed seemingly free-floating in the PDL and they
resembled mature bone and revealed necrosis. The newly formed tissue in the root notch
was thick, had an irregular surface contour, was devoid of extrinsic fibers, contained
embedded cells, and the cells on the matrix surface were very large. The superficial
thickened tissue layers that were observed apical to the notch area or at sites where no notch
was discernible were clearly distinguishable from the old cementum by their lighter staining.
These layers were less thick than the tissues that formed in the notch and were found on both
the root surfaces with or without scaling markings. A gap was consistently observed
between the treated root surfaces and the newly formed mineralized tissues in the coronal-
most portion of the instrumented area. The gap appeared empty or was filled with an organic
material resembling scattered or colonies of bacteria.
TEM: The matrix of the newly formed tissue on the root was collagenous. The collagen
fibrils were randomly oriented and loosely packed and a distinct mineralization front was
not discernible. However, large electron dense matrix patches were scattered in and adjacent
to the new tissue. The cells that lined the new tissue were very large and possessed abundant
cisternae of rER and a prominent Golgi complex. The coronally located gap was filled with
scattered or colonies of bacteria occasionally with RBCs or WBCs. It may be stated that
instead of the development of AEFC (acellular extrinsic fiber cementum), a partially
mineralized CT formed that contained many embedded cells, but no extrinsic fibres. This
tissue may be thus classified as bone-lide or as cementum-like tissue resembling CIFC
(cellular intrinsic fiber cementum).

Trejo PM, Weltman RL. Favorable periodontal regenerative outcomes from teeth
with presurgical mobility: a retrospective study. J Periodontol 2004;75:1532-28.

Purpose: To evaluate the effect of presurgical tooth mobility on periodontal
regenerative outcomes of intrabony defects after 1 year of healing.

Materials and Methods: The data in this study were derived from three previously
conducted clinical trials which had evaluated regenerative procedures. 64 patients
(average 49.5 years) with one intraosseous defect each met the inclusion and
exclusion criteria required for this study. The grouping yielded 36 teeth with
physiologic mobility score 0, 13 teeth with mobility of 1, and 15 teeth with mobility
of 2. Different regenerative therapies in intrabony defects received one of the
following treatment: e-PTFE barrier, polyactic acid (PLA) barrier, PLA combined
with DFDBA allograft, EMD, and EMD combined with DFDBA. Patients
completed the hygienic phase of therapy 1 to 2 months before the baseline
examination. Patients received a baseline examination were monitored at several
intervals immediately post-surgically, and were marinated for a period of 1 year.
After 1 year, the periodontal parameters were reevaluated. The following variables
were measured at baseline and at 12 months post-surgery: PD, CAL, position of the
gingival margin from CEJ (REC), BOP, PI, GI, OLeary plaque control, and tooth
mobility using the Miller index. In each of the independent trials the post-
surgical follow-up and maintenance periods were carried out to achieve the best
possible control.

Findings and Conclusions: All patients achieved and maintained a plaque control
record value of <20% throughout the duration of the studies. In all three tooth
mobility, regenerative therapy resulted in increased gingival recession 12 months
after surgery. The probing depth reductions from baseline to 1 year with TM score 0
was 3.67mm; for TM score 1, 2.81mm; and for score 2, 3.73mm. The gain in
clinical attachment level in the TM 0 group, 2.73mm, group TM 1 1.96, and group
TM2 2.36mm. Comparison results between the tooth mobility groups utilizing the
delta values; i.e. change in the primary outcome variables of PD, CAL, and REC
after 1 year in each group was not statistically different.
1. Maintenance therapy on intrabony defects results in stable attachment levels
over time.
2. Interproximal, intraosseous defects of teeth with limited presurgical tooth
mobility (Millers Class 1 and 2), will respond favorably to regenerative
therapy.
Stavropoulos F, Dahlin C, Ruskin JD, et al. A comparative study of barrier
membranes as graft protectors in the treatment of localized bone defects: An
experimental study in a canine model. Clin Oral Impl Res 2004; 15(4): 435-42.
(32 Refs)

Purpose: To compare a new resorbable membrane composed of 67% glycolide
(PGA) and 33% trimethylene carbonate (TMC) with a resorbable collagen
membrane, with assayed DFDB serving as GM in an experimental bone defect

Materials and Methods: 5 adult male foxhound dogs were included in the study.
Prior to the surgical protocol, the mandibular first, second, third and fourth premolars
and the first molars were extracted bilaterally. Three osseous saddle-type defects,
measuring 8mm (apicocoronal) x 10mm (mesiodistal), were prepared in the
edentulous mandibular premolar area by removing the buccal and lingual plates and
associated cancellous bone. 5 membranes were used in this study: 4 membranes were
composed of 67% PGA: 33%TMC (Groups A-D), each with a different porosity, and
a fifth membrane was a collagen membrane (Group E). Each surgical site was filled
with canine DFDB and selected to receive one of 5 membranes. One site in each
animal did not receive a membrane and served as a control (Group F). After 3
months, the animals were euthanized, and three sections were prepared from each
defect: central, mesial, and distal sections. A section of about 100thickness was
microradiographed and it was further ground to about 10 for light microscopic
investigation. With the aid of a grid, the following estimators were examined: 1. new
bone, 2. soft tissue, 3. DFDB (GM), and 4. bone +DFDB (GM).

Findings and Conclusions: All the surgical sites demonstrated uncompleted healing,
and the DFDB showed a high turnover and incorporated within the newly
regenerated bone. Group F (DFDB only) exhibited noticeable deformation in the
profile of the regenerated bone, and a knife-edge ridge was created via a partial
collapse of the buccal and lingual walls. Group F also demonstrated significantly less
new bone formation compared with all the other groups using barrier protection. In
Group E (collagen membrane), a thicker soft tissue layer could be seen within the
regenerate compared with Groups A-D (PGA:TMC-type membranes). Regardless of
the different level of porosity, Groups A-D demonstrated significantly more bone
content and higher percentage of new bone within the regenerate compared with
Group E. The reason for above results is as yet unknown. However, it has been
proposed that differences in mechanical properties, degradation time and lack of
integrated biologic components could be factors influencing the regenerative
outcome. This study provides evidence that the combination of a PGA:TMC
biodegradable membrane +DFDB offers a viable alternative in the treatment of
localized bone defects in the clinical setting.
Sculen A, Windisch P, Chiantella G. Human histologic evaluation of an intra
bony defect treated with enamel matrix derivative, xenograft and GTR. J Clin
Perio: 2004. Vol 24; 327-333. (28 Refs)

Purpose: The purpose of this case report was to clinically and histologically
evaluate the healing of one advanced intra bony defect following treatment with an
enamel matrix derivative (Emdogain EMD) combined with a bovine-derived
xenograft (BDX) and guided tissue regeneration.

Materials and Methods: A 54 year old man who was a non smoker and in good
general health with a history of chronic adult periodontitis was selected for this
study. The patient had one intra bony defect localized at the mesial, palatal and distal
aspects of the maxillary right central incisor. This tooth was deemed to be
unsalvageable and was scheduled for extraction. Two months prior to the surgical
procedure, the patient received full mouth Sc/RP. The clinical parameters evaluated
prior to the surgery included probing depth (PD), gingival recession (GR) and
clinical attachment level (CAL). Radiographs were taken prior to and after
extraction. Following reflection of mucoperiosteal flaps and degranulation of the
osseous defect, the root surface was thoroughly root planned. Notches were prepared
on the root surface at the level of the calculus and alveolar crest. The root surface
adjacent to the osseous defect was treated with 24 % EDTA for two minutes. The
defect and adjacent mucoperiosteal flaps were thoroughly rinsed with saline and
EMD was then applied on the root surface. The remaining EMD was mixed with
BDX and the defect completely filled with the mixture. A bioresorbable collagen
membrane was adapted over the defect and 2-3 mm of surrounding alveolar bone.
The surgical site was closed and the patient placed on a one week course of
antibiotics. Recall appointments were carried out once per week for the first week
and once per month for the next seven months. Following this period the patient
underwent a second surgery at which time, mucoperiosteal flaps were reflected, and
the tooth extracted with some of its surrounding hard and soft tissue. The specimen
was then sent for histologic analysis.

Findings and Conclusions: Pre operatively the PD was 9mm and the CAL loss was
11 mm. The intrabony defect measured 4 mm as measured during surgery. The 7-
month post-operative examination revealed a PD of 3mm and a CAL of 7 mm. An
increased radioopacity was also noted at this time. Histological analysis showed that
the healing was characterized by formation of a new PDL, cellular cementum and
bone. Most of the BDX particles were surrounded by bone-like tissue. No direct
contact between the graft material and the tooth surface was observed. Healing in
the suprabony defect occurred through epithelial down growth that stopped at the
level of the coronal notch. Here no cementum or bone formation was observed and
the BDX particles were completely encapsulated in connective tissue.
Schulean A, Pietruska M, Schwarz F, et al. Healing of human intrabony defects
following regenerative periodontal therapy with an enamel matrix protein derivative
alone or combined with a bioactive glass. J Clin Periodontol 2005; 32: 111-117.

Purpose: To compare clinically the treatment of deep intrabony defects with a
combination of an enamel matrix protein derivative (EMD) and a bioactive glass
(BG) to EMD alone.

Materials and Methods: 30 patients with advanced periodontitis were included in
the study. The inclusion criteria included presence of at least one intrabony defect
with PD 6mm & an intrabony component of at least 3mm as detected on
radiographs. One week prior to the therapy and 1-year post operatively, PI, GI, BOP,
PD, GR, & CAL were recorded. Pre & post treatment radiographs were taken with
its paralleling technique. The defects were randomly assigned to treatment group of
EMD + BG & EMD alone. During the surgery, CEJ-BD (CEJ to bottom of the
defect), CEJ-BC (CEJ to bone crest), was measured & INTRA (intrabony
component) was measured. Statistical analysis was performed.

Findings and Conclusions: The post operative healing was uneventful. The mean PI
did not reveal a statistically significant difference in either group. PI & BOP
improved in both the groups. No differences in distribution of defects were found in
both the groups. At 1 year, the EMD+BG group showed reduction in mean PD from
8.5 1.1 to 4.4 1.2mm and a change in mean CAL from 10.2 to 6.3.In the test
group, 12 sites gained at least 3mm or more of CAL, whereas in the control group a
CAL gain of 3mm or more was measured at 13 sites. No statistically significant
differences in terms of PD reduction & CAL gain were observed between the two
groups. A re-entry surgery was performed in 2 cases from each group (T=4 cases)
indicating a fill of osseous defects. At 1 year after surgery both therapies resulted in
significant PD reductions & CAL gains and the combination of EMD+BG does not
seem to additionally improve clinical results.
Scabbia A, Trombelli L. A comparative study on the use of a
HA/collagen/chondroitin sulphate biomaterial (Biostite) and a bovine derived HA
xenograft (Bio-Oss) in the treatment of deep intra-osseous defects. J Clin
Periodontol 2004; 31: 348-355. (64 Refs)

Purpose: To evaluate the clinical outcome of deep intra-osseous defects following
reconstructive/regenerative surgery comparing the use of Biostite and Bio-oss
materials.

Materials and Methods: A parallel-group, randomized, clinical trial was performed
with 24 healthy patients with moderate to advanced periodontitis, comprising 11
females and 13 males, mean age 47.5 yrs (seven smokers among them), were
selected. Patients were divided into (13 test and 11 control) and were treated for 1
defect (interproximal intra-osseous defect >4mm confirmed both radiographically
and clinically at surgery) comprising a total of 24 defects. Presurgery, all patients
received an examination with records, oral hygiene instruction, and multiple scaling
and root planings. A minimum of 4 weeks elapsed between non-surgical therapy
(baseline) and surgery. 13 defects were treated with Biostite and 11 defects with
Bio-oss. Clinical recordings were repeated at 6 and 12 months post-surgery.
Radiographic assessment repeated at 12 months post-surg.

Findings and Conclusions:
Table 2 PPD CAL
Baseline 6 months 12 months baseline 6 months
12 months
Biostite (N=13) 7.8+/-1.3 4.5+/-2.1* 3.6+/-1.6* 9.0+/-1.6 6.7+/-2.3*
6.1+/-1.9*
Bio-Oss(N=11) 7.5+-2.0 3.6+/-1.3* 3.1+/-1.0* 9.0+/-2.0 5.8+/-1.5*
5.0+/-1.5*
P 0.6988 0.3878 0.7793 0.9503 0.3028
0.2190
Table 3.
Outcome Variable Biostite N=13 Bio-Oss N=11 p-value
CAL gain 2.9+/-1.9 4.0+/-2.5 0.2190
PPD reduction 4.2+/-2.1 4.4+/-2.3 0.7793
REC increase 1.2+/-1.9 0.4+/-1.8 0.2696
DEPTH gain 2.5+/-1.4 3.1+/-1.8 0.3940

Table 4.
CAL
0-2 mm >2 to 4 mm >4 mm
Biostite N=13 6 3 4
Bio-Oss N=11 4 2 5

The outcomes clearly show improvement with the use of both materials that can be
measured clinically and statistically in PPD, CAL, and radiographic DEPTH gain.
Rothamel D et al. Biocompatibility of various collagen membranes in cultures of
human PDL fibroblasts and human osteoblast-like cells. Clin Oral Impl Res
2004;15:443-449.

Purpose: To evaluate the biocompatibility of differently cross-linked collagen
membranes in cultures of human PDL fibroblasts and osteoblast-like cells.

Materials and Methods: Four commercially available membranes used for
GTR/GBR procedures viz Biogide, Biomend, Ossix and Tutodent were tested for
their biocompatibility. 12 specimens of each membrane type were used. Six of them
were covered with PDL fibroblasts and the other six in osteoblasts. Controls were
cells plated on culture dishes. The incubation period was 7 days. All samples were
examined for cell count under light microscope. SEM observation was done as well.

Findings and Conclusions: The highest number of PDL fibroblasts were seen on
the positive control. Biogide and Ossix membranes had the next greatest number of
fibroblasts with the difference between them being insignificant. Biomend had least
number of PDL fibroblasts attaching and proliferating on it. In the osteoblast culture,
the controls had the highest cells, followed by Biogide and Tutodent, with the
difference between them being statistically insignificant. Ossix showed much less
cells, while Biomend showed no detectable osteoblasts. SEM observations on the
morphology of cells revealed that PDL fibroblasts that adherent on Biogide,
Tutodent, and Ossix resembled the cells on the controls appearing spindle shaped
and flat. The osteoblasts like cells on the control were star shaped and flat but mostly
round in shape on the Biogide, Tutodent and Ossix samples, while there was no
attachment or proliferation on Biomend. As a conclusion, the authors opine that
Biogide, Tutodent and Ossix promoted, while Biomend inhibited the attachment and
proliferation of human PDL fibroblasts and human Osteoblast like cells.

Murphy K, Gunsolley J. Guided tissue regeneration for the treatment of
periodontal intrabony and furcation defects. A systematic review. Ann
Periodontol 2003;8:266-302. (198 Refs)

Purpose: To assess the efficacy of GTR procedures in patients with periodontal
osseous defects compared with surgical controls on clinical, radiographic, adverse,
and patient-centered outcomes.

Materials and Methods: Literature review. The following comparisons were
made:
1. GTR versus open flap debridement (OFD).
2. GTR using a barrier plus some form of augmentation, usually a particulate
bone graft, versus GTR procedure alone.
3. GTR using ePTFE barrier versus GTR using a bioabsorbable barrier type.
4. GTR using one surgical protocol versus GTR using a different surgical
protocol but the same barrier material type, based upon the flap closure
technique employed.
5. GTR using one post-operative recall care regimen versus GTR using a
different post-operative recall care regimen.

Outcomes:
Short-term: CAL measured in both a vertical (VPAL) and horizontal (HPAL)
direction, PD measured in both a vertical(VPD) and horizontal(HPD), gingival
recession (REC) increase, for furcation-defects, bone levels assessed
radiographically and/or at re-entry for intra-bony defect studies and HOPA and
VOPA for furcation-defect studies and oral hygiene efficacy and compliance using
full mouth bleeding scores (FMBS) and complications related to surgical treatment
were recorded.
Long term: Tooth retention, FMBS and disease recurrence was measured.
Patient-centered: complications related to surgical treatment, ease of maintenance-
residual PD and esthetics as defined by REC in anterior teeth were considered.

Findings and Conclusions:
Long-term results:
The review failed to identity any studies which evaluated patient outcomes
for more than 5 years. Therefore no statement can be made regarding the
efficacy of periodontal therapy using physical barriers enhancing tooth
retention.
Providing patients with a periodontium that is easier to maintain is
indirectly related to probing depth reduction and is manifested in post-
treatment gingival bleeding indices. Reductions in PD and gain in CAL as
surrogate variables were uniformly enhanced in GTR procedures as
compared to OFD controls.
Patient-centered outcomes, such as surgical complications and esthetically
unacceptable results were not consistently reported. When reported, the
incidence of abscess formation was 15% or less.

Intrabony defect studies:
Barrier vs OFD: GTR resulted in a greater gain in CAL and reduction in
PD when compared to OFD controls independent of the barrier type
employed. REC between the test and control were not significant, but
usually were larger in the test group regardless of the barrier type.
However, studies that utilized some form of advanced flap management
resulted in a decrease in post-treatment recession as compared to OFD
controls.
ePTFE vs bioabsorbable barriers: No significant difference when
evaluating CAL gain or PD reductions or REC detected.
Barrier vs barrier plus augmentation material: DFDBA when used in the
test group did not produce any difference in CAL gain or PD reductions.
Hard tissue changes: Only one study favored OFD when using re-entry
assessment was done. None of the studies demonstrated a loss or lack of
bone volume gain in the GTR group, while one study revealed a lack of
bone volume gain in the OFD control group.

Furcation studies:
Barrier vs OFD: GRT resulted in greater gain in VPAL when compared to
OFD controls. Analysis on the effect of furcation location (maxillary vs
mandibular; proximal vs facial or lingual) failed to show a difference
between sub-groupings. GTR results in a greater VPD reduction as
compared to OFD. Collagen barrier usage usually resulted in greater gains
in VOPA, however, statistical analysis was not performed to confirm this
trend. The re-entry outcome variable HOPA was in favor of GTR when all
barrier types were compared. Post-treatment PEC induced by the use of the
physical barrier was also not significant when compared to OFD.
ePTFE vs bioabsorbalble barriers: A statistical difference in favor of
bioabsorbable barrier types over ePTFE could be detected for VPAL, but
not for VPD.
Barrier vs barrier plus augmentation material: VPAL was significantly
enhanced by the addition of a particulate bone graft compared to ePTFE
alone. Polymeric or cellulose barrier treatments were not enhanced by the
use of a graft. VPD reductions were also enhanced by the addition of a
particulate graft when all barriers were collectively reviewed especially
with ePTFE. Outcome variable HOPA demonstrated an advantage to the
use of augmentation material in addition to the GTR barrier.

Possible prognostic factors:

Flap closure: Most studies utilized a standard flap closure.
Flap closure ranking:
Grade 1: No attempt to cover barrier with flap or a standard technique.
Grade 2: Periosteal fenestration or split-thickness dissection to facilitate
passive flap adaptation; interrupted sutures. Some form of papilla retention is
used.
Grade 3: MPPT or SPPT with some from of mattress suturing.

Examining intrabony defects and considering all barrier types, no
significant differences between the rankings could be detected. However,
when considering only ePTFE barriers, the mean gain in CAL utilizing a
specialized flap closure technique was 3.76 as compared to 2.90 mm and
2.84 mm for grades 2 and 1 respectively, though not statistically
significant.
Flap closure technique grade 3 was not used for any of the furcation-defect
studies examined. With the exception of HPD reduction, no other
difference in any outcome variable was seen. HPD reduction was enhanced
when a passively adapted, coronally repostitioned flap technique was
employed.
The use of specialized flap techniques may enhance clinical outcomes, but
there are insufficient data at this time to demonstrate superiority with the
use of these techniques.

Frequency of postoperative recall care:
Recall protocol:
Grade 1: No weekly care stated in protocol or wound stabilization for 6 weeks
or 2 or less interventions for the first month; longer than monthly intervals for
the remainder period or 3 or more interventions for the first month, longer than
a monthly interval but less than or equal to a 3-month interval for the
remainder period.
Grade 2: At least bi-weekly for the first 6 weeks, then every month thereafter.
Grade 3: Weekly for the first 2 months, then bi-weekly or monthly thereafter.

Studies that utilized a more frequent recall interval, especially in the time
period after 3 months, showed a tendency for greater gains in CAL, VPAL,
HPAL, HOPA.
A monthly frequency maintenance schedule (Grade 2) results in PD
reduction, but the use of this regimen does not statistically improve CAL
outcomes in GTR.

Timing of barrier removal:
The most commonly used time rage was 4 to 6 weeks. Therefore,
differences in the effect of barrier removal at the 4- and 6-week time
intervals could not be discerned from this dataset.
2 studies allowed the barriers to remain for 8 weeks but reported to
statistically significant enhancement in VPAL.

Meyle J, Gonzales JR et al. A randomized clinical trial comparing Enamel Matrix
Derivatives and membrane treatment of buccal Class II furcation involvement in
mandibular molars. Part II: Secondary outcomes.
J Periodontol 2004;75:1188-1195

Purpose: to compare Enamel Matrix Derivatives (EMD) and membrane treatment of
buccal class II furcations in mandibular molars with regard to secondary outcomes.

Materials and Methods: 45 patients with 90 comparable defects on contralateral
molars were included. Patients were recruited at four university dental schools and
one private periodontal practice. Patients all had buccal Class II furcation
involvements (horizontal probing depth of >3mm) in both lower first or second
molars. The selected teeth were required to have proximal bone levels at or above the
fornix of the furcation. In addition, they had to present with a zone of keratinized
tissue of at least 2 mm adjacent to the furcation defect, in order to provide coverage
of the furcation entrance during surgery. Defects were randomly assigned to EMD or
bioabsorbable barrier membrane; the contralateral defect received the alternative
treatment. Assessment at baseline and 8 and 14 months included gingival margin
levels(GM), probing depths(PD), bleeding on probing(BOP), vertical attachment
levels(AL), and vertical bone sounding(BS) from a stent at five buccal sites/tooth,
which included the primary outcome. Defect dimensions were recorded at surgery
and during reentry at 14 months. The secondary outcome was reported here: changes
in hard tissue boundaries describing the anatomical situation of the furcation defect
and changes in the clinical parameters (GM, PD, BOD, AL) between baseline and 14
months. The hard tissue boundaries in the furcation defect and the clinical parameters
were measured twice, using as reference the CEJ and the individually manufactured
acrylic stent with grooves at five sites. Descriptive statistics were applied for changes
in clinical parameters and measurement of hard tissue boundaries. The differences
observed under treatment with EMD or membrane were analyzed by means of the
Wilcoxon two-sample test.

Findings and Conclusions: the median reduction of PD in the mid-furcation site
changed from 3.5mm at baseline to 3.0mm after 14 months in sites treated with EMD,
and in membrane treated sites from 3.25 to 3.0mm. The median reduction of AL in
the mid-furcation site changed from 7.5mm at baseline to 7.0mm after 14 months
with EMD treatment, and from 7.38mm to 7.0mm with membrane treatment. A
reduction in the frequency of BOP in the mid-furcation site was determined with both
treatments, changing from 40% at the beginning of treatment to 21.3% (EMD) and
23.4% (membrane) after 8 months. However, after 14 months, a further reduction of
BOP was shown only with EMD treatment and not with the membrane treatment.
Different treatment effects could be detected for the distances from the stent or
cemento-enamel junction (CEJ ) to the buccal bone crest, mid-mesial root and the
distance from the stent or CEJ to the buccal bone crest, mid-mesial root. There was
no measurable bone resorption in EMD sites, whereas a slight resorption occurred
with membrane treatment. Furcation morphology at the time of surgery was not
associated with clinical outcome, irrespective of the treatment. This study
demonstrates equivalent clinical results when treatment with EMD was compared
with GTR using bioabsorbable membranes in treating mandibular Class II furcations.
Evaluation of clinical and osseous changes associated with this study indicated that
treatment with EMD led to similar regenerative outcomes as the GTR procedures.
Kostopoulos L, Karring T. Susceptibility of GTR-regenerated periodontal
attachment to ligature-induced periodontitis. An experiment in the monkey. J
Clin Periodontol 2004; 336-40 (20 Refs)

Purpose: To compare the susceptibility of GTR-regenerated periodontal attachment
to ligature-induced periodontitis with that of the pristine periodontium.

Materials and Methods: Four monkeys were used. In each monkey, a first
maxillary premolar and molar and a mandibular lateral incisor were selected as test
teeth and subjected to periodontal breakdown by placing orthodontic elastics around
them. After 2-3 months the elastics were removed and tooth cleaning once a week
was instituted. After 1 month a mucoperiosteal flap was elevated around test teeth
and the root surfaces were scaled and planed. A notch was prepared in the root
surface at the level of apical extension of the infrabony defect. Subsequently, the
crowns of the teeth were cut off at CEJ and root canals filled. For multi-rooted teeth
the buccal roots were extracted and only the palatal root was retained. An e-PTFE
membrane was adapted over each root and was covered by a coronally displaced
flap. Five weeks later the membrane was removed. At this time, a flap operation
was also performed on the contra-lateral control teeth. The teeth were similarly cut
off at CEJ , root canals prepared and flaps sutured back. After a 3 month period of
tooth cleaning twice a week, the cleaning was abolished and cotton floss ligatures
were placed around all experimental teeth to facilitate plaque accumulation. After 6
months the ligatures were removed and 2 weeks later the animals were sacrificed.
The jaws were fixed and stained with H&E or Heidenhains azan variant stain. Five
sections from midpoint of the root, 80 um apart were used for analysis. The
following linear distances were measured; PD, LOA, coronal bone level, apical
bone level, amount of newly formed attachment and bone.

Findings and Conclusions: The results of 24 control and test surfaces were
analysed with the Wilcoxon test for paired observations (split mouth design).
Except for the cementum on the root surface, the control and test roots exhibited
similar histologic features.
1. New cementum was identified on all test roots coronal to the notch in the
root surface and below the attachment level, covering about 2/3 of the entire
length of the instrumented surface.
2. New cementum was of the reparative, cellular, extrinsic and intrinsic fiber
type. However, the pristine cementum on the control roots was mainly
acellular, extrinsic fiber cementum with areas of cellular, extrinsic and
intrinsic fiber types.
3. The new cementum in the apical portion was considerably thicker than the
pristine cementum in the control specimens and frequently a split was
present between the new cementum and the root surface.
4. Epithelium was never seen between the detached cementum and the root
surface.
5. Regrowth of alveolar bone had occurred in all test specimens.
6. Histometric analysis reveled only the difference in pocket depth between
test and control roots to be statistically significant (P<0.05).

Klepp M. Histologic evaluation of demineralized freeze-dried allografts in barrier
membrane covered periodontal fenestration wounds in ectopic sites in dogs. J Clin
Periodontal 2004:31;533-44 (48 Refs)

Purpose: To histologically examine the healing responses of periodontal
fenestration defects grafted with Ethylene Oxide (EO)-sterilized, heat-treated or non-
sterilized DFDBA beneath barrier membranes as compared with ungrafted control
sites beneath barriers. A secondary objective was to compare the healing
characteristics of DFDBA embedded in ectopic sites in the animals and to contrast
the response with those observed in the fenestration defects.

Materials and Methods: Fifteen adult mongrel dogs with no clinical evidence of
periodontitis were selected. Bone allograft material was obtained from the American
Red Cross Transplantation services and additional material, specifically cortical
bone, procured from mongrel dogs. All barrier membranes for both test and control
groups were ePTFE in construction. 8 mm in diameter, circular fenestration defects
were created bucally at all four canines in each of 14 dogs. Each site then received
one of the following grafts beneath the membranes: (a) EO-sterilized DFDBA
allograft, (b) heat-treated DFDBA, (c) non-sterilized DFDBA and (d) ungrafted
control. 12 dogs had three subcutaneous chest wall pouches created and one of the
three graft materials (0.1cm3) placed. Animals were evaluated for healing
complications at 4 weeks and data recorded, then all were euthanized and block
specimens obtained. Sections were quantitatively analyzed for: (1) total defect area,
(2) graft particle area within the defect and (3) new bone within the defect.
Subcutaneous specimens were evaluated histologically and quantified for associated
inflammatory cell infiltrate.

Findings and Conclusions: Defects healed incompletely with partial bone fill and
cementum regeneration and formation of a periodontal ligament. Graft particles
present in the healing defects were typically isolated from the sites of osteogenesis,
although some were incorporated into the newly formed bone. No statistically
significant differences in new bone formation were observed between treatment
groups within animals, but significant inter-animal variation did exist. Overall, bone
augmentation was successful when the barrier was present and stable, in the majority
of sites. Subcutaneously, in close proximity to the graft material, inflammatory
infiltrates of varying intensity were observed between specimens. In conclusion, the
present studys choice of 8mm defects was chosen based on previous research with
the addition of a barrier. Previous research using barrier membranes found more
emphasis on healing time than defect size. The authors demonstrated relative
predictability of tissue regeneration with total success likely dependent on surgical
execution and, specifically, available osteogenic factors found in graft material.
Kawaguchi H, Hirchi A, Hasegawa N, et al. Enhancement of periodontal tissue
regeneration by transplantation of bone marrow mesenchymal stem cells. J
Periodontol 2004;75:1281-7.

Purpose: To evaluate the potential of bone marrow mesenchymal stem cells
(MSC), expanded by the culture system, on periodontal tissue regeneration in
vivo.

Materials and Methods: The study was conducted on 12 female beagle dogs.
Scaling and tooth brushing was performed to obtain good oral health. Bone
marrow aspirates were taken from the iliac crest of each animal. The cells were
cultured and harvested. Class III furcation defects were surgically created at the
2
nd
, 3
rd
, 4
th
premolars in each dog. Each defect measured 4 mm from the CEJ to
the reduced alveolar crest. The root surface was denuded and the periodontal
ligament and cementum were removed. Reference notches were placed. MSC-
collagen gel was used in the experimental defects while atelocollagen alone was
used in the control group. The flaps were coronally repositioned and sutured.
After 1 month the animals were sacrificed, block sections were obtained,
processed and studied.

Findings and Conclusions: In the experimental group, a significant amount of
new bone and adequate width of periodontal ligament were seen. The denuded
root surface was almost completely covered with new cementum, and regenerated
periodontal ligament separated the new bone from the new cementum. Complete
bone reconstruction was not obtained. Epithelial cell invasion, bone ankylosis,
and root resorption were not seen on the root surface. In the control group,
epithelial cells invaded into the top of the furcation and no cementum
regeneration was observed in the area. Less bone regeneration was present. Bone
ankylosis and root resorption were not seen. The % of new cementum length
ranged from 91.3% to 96.7 % in the test group compared to 70.5 % in the control.
The % of new bone area in the test group ranged from 62.5 % to 68.1% compared
to 54.8% in the control. The % of bone area in the normal specimen was 73%.



Hartman GA et al. Clinical and Histologic Evaluation of Anorganic Bovine bone
Collagen with or without a Collagen Barrier. Int J Periodontics Restorative Dent
2004; 24:127-135.

Purpose: To evaluate an anorganic bovine-derived xenograft (Bio-Oss Collagen) in the
treatment of human periodontal defects.

Materials and Methods: Four patients with radiographic evidence of one or more
osseous defects with deep vertical bone loss on teeth that were scheduled for extraction
were enrolled in the study. Presurgical measurements of probing depth, clinical
attachment levels, and recession were recorded. The surgical procedure consisted of flap
reflection, debridement of the osseous defects and root surface, placement of a notch
through calculus into the root surface, topical application of a tetracycline paste to the
root surface, grafting with Bio-Oss Collagen, and flap closure. Three of the eight defects
examined received a resorbable collagen barrier (Bio-Gide) in addition to the bone graft.
Patients were seen every 2 weeks for plaque control and review of oral hygiene measures.
Six months postsurgery, clinical parameters were rerecorded prior to en bloc resection of
teeth and adjacent graft sites.

Findings and Conclusions: Overall the results showed a substantial amount of probing
depth reduction and clinical attachment level gain for all sites tested. The range of
clinical attachment level gain was 0 to 8mm, probing depth reduction varied from 1 to
10mm, and recession varied from 0 to 5mm. The defects examined in this study were all
either one or two walled defects, suugesting that he major portion of the defects was non
contained. There was no apparent correlation between the number of osseous walls of the
defect and the clinical parameters. Histologic evaluation and histomorphometric
measurements demonstrated new bone, cementum, and periodontal ligament coronal to
the reference notch in two of the eight specimens. Two sites demonstrated new
attachment, and four showed a long junctional epithelium. Clincally, there were no
differences in the results between the sites that received the combination of the graft and
membrane versus those with the graft alone. There appeared to be a greater degree of
mean probing depth reduction (6.8mm vs 4.3 mm), as well as mean clinical attachment
level gain (5.3mm vs 2.3 mm), for the defects treated with bone replacement graft alone.
However, the number of samples was too small to make meaningful comparisons.
Periodontal regeneration is possible following a bone-replacement graft of Bio-Oss
Collagen.
Hagenaars S, Louwerse HG, Timmerman et al. Soft-tissue wound healing
following periodontal surgery and Emdogain application. J Clin Periodontol
2004;31:850-856.

Purpose: To compare the effect of Emdogain on soft-tissue healing by clinical and
patient-perspective means.

Materials and Methods: 22 subjects that were scheduled for flap surgery were
selected. Initial therapy was performed and at re-evaluation, patients were included
for surgery if PPD5mm. Randomization was done and it so happened that all
smokers were in the test (EMD) group. MWF was performed on each patient and
minimal bone recontouring was performed if necessary. The distances from the
marginal gingival to the alveolar bone and the CEJ to the alveolar bone was
measured with a periodontal probe. Presuturing was done and Emdogain was used in
the test group that had 11 patients while the control group with 12 patients received
none. Clinical parameters used were swelling of the soft tissues, color of the
gingival, PPD, CAL, BI, PlI. During the first 7 days, the patients filled out a
questionnaire to evaluate the experience of post-operative complaints using a VAS.
The clinical parameters were measured at 1, 4, 8 weeks post surgery.

Findings and Conclusions: At 8 weeks, the gain in clinical attachment was .042 and
0.67 for the test and control group. The reduction in PPD was 0.71 and 0.74 mm
respectively. The mean BI was 0.18 and .016. Swelling and redness showed no
significant differences either. On the VAS for pain, on a scale from 0 to 10, the test
group Vs the control was 3.35 and 1.90 on day 1. On day 7, the score was
insignificant. Swelling of the mucosa and face was observed in both groups with no
significant difference. The day after surgery twice as many patients in the control
group experienced oozing of blood from the site. In conclusion, the initial wound
healing with or without Emdogain presents with no significant results.


Gurinsky B, Mills M, Mellonig J. Clinical evaluation of Demineralized Freeze-
Dried Bone Allograft and Enamel Matrix Derivate alone for the treatment of
periodontal osseous defects in Humans. J Peridontol 2004: 75; 1309-18 (52Ref)

Purpose: To evaluate the use of DFDBA in combination with EMD compared to
EMD alone in the treatment of human intrabony defects

Materials and Methods: Forty systemically healthy patients (23 females, 17 males)
between ages of 19 and 76years were selected for this single-mask, parallel design,
randomized, controlled clinical trial. Patient were selected based on the following
criteria: 1- at least one site was determined to be in need of periodontal surgery after
initial therapy; 2- PD >5mm; 3- intrabony lesions with a depth >3mm and 4- age
between 18-80 years. Soft and hard tissue measurements were recorded. Soft tissue
measurements included: 1- distance from the CEJ to the FGM; 2- FGM to the base of
the pocket and 3- CEJ to base of the pocket to calculate pocket depth, gingival
recession and clinical attachment gain. Hard tissue measurements were taken at
baseline and 6-months at reentry surgery to determine defect depth, defect fill, %
defect fill, defect resolution and alveolar crest resorption. These measurements
included: 1- distance from CEJ to the base of the defect; 2- CEJ to the alveolar crest;
3- alveolar crest to the base of the defect; 4- Description of the osseous wall
morphology and 5- periapical radiograph. A total of 67 sites were selected randomly
as experimental group (34 sites) treated with DFDBA +EMD or as control group (33
sites) treated using EMD alone. All patients received prophylaxis at baseline and at
each POT visit at 7-10 days, 25-30 days, 3 and 6 months. A paired t-test was used to
compare soft and soft tissue measurements the day of surgery and 6-months POT.
Distributions of defects by geometry (#wall defect), arch (mandibular/maxillary)
and tooth location in the arch were analyzed by treatment mode and quality of result

Findings and Conclusions: Clinical evaluation, Post operative healing was similar
for both groups. Analysis of the sites based on maxillary versus mandibular sites,
tooth type, age and gender revealed no significant difference in any measured
parameters (P<0.10 chi-square test). Initial PD, CAL and defect depth were 7.5mm,
8.1 mm and 4.9 mm respectively for control group and 7.5 mm PD, 8.2mm CAL and
5.2mm DD for the experimental group. At 6-months soft tissue measurements
demonstrated significant improvement from baseline, however no significant
difference was observed between the two groups. Probing depth reduction (PDR) for
experimental group was (3.6mm+- 0.2), while for EMD alone PRD was (4.0+-0.3);
CAL for DFDBA +EMD group was (3.0mm +-0.3) and EMD alone (3.2mm+-0.3).
Mean increase in recession was 0.7mm+-0.2 for EMD group and 0.5mm+-0.3 for
DFDBA+EMD group. Hard tissue measurements demonstrated a greater amount of
crestal resorption for the EMD group (0.9mm+-0.2) than EMD+DFDBA group
(0.1mm+-0.2) (P0.04). Mean value for bone fill for EMD group was (2.6mm+-0.4)/
55.3% and for the DFDBA+EMD group was (3.07mm+-0.2)/ 74.9%. Percentage for
defect resolution for the DFDBA +EMD group was 75.7% and for the EMD alone
group was 69.2%. Percentage of sites gaining more than 50% bone fill were 26.9%
for EMD+DFDBA and 47.8% for EMG alone. Sites gaining greater than 90% bone
fill were 26.9% for EMD+DFDBA group and 17.4% for EMD alone group. This
study demonstrated that EMD alone and in combination with DFDBA is a clinical
safe product to use in treating human intrabony defects and can improve soft and
hard tissue parameters from the baseline measurements. However DFDBA+EMD
demonstrated an improvement in the hard tissue parameters over that achieved with
EMD alone.



Yukna RA, Vastardis S. Comparative evaluation of decalcified and non-decalcified
freeze-dried bone allografts in rhesus monkeys. I. Histologic findings. J
Periodontol 2005;76:57-65. (49 Refs)

Purpose: To compare new bone formation associated with undecalcified and
decalcified allogenic freeze-dried bone allografts in orthotopic alveolar bone sites in
rhesus monkeys.

Materials and Methods: Six rhesus monkeys were used in the present study. The
animals were sedated and a full thickness flap was elevated. Either DFDBA or
FDBA was implanted into surgically created vertical grooves (4 mm deep and wide
and 10-12 mm long) on the facial aspects of all posterior quadrants. Nylon mesh of
250 m pore size was used a container of grafting bone. Each quadrant received
three cylinders containing one type of bone and one empty cylinder. The cylinders
were retrieved at 1, 2, and 3 months and processed for histologic and histometric
evaluation.

Findings and Conclusions: FDBA chambers contained more new bone
and total bone than either the DFDBA or E chambers at all time periods. DFDBA
was not statistically significantly different than empty control at any time period.
FDBA had less old bone than DFDBA at 3 months.
The results suggested that FDBA may stimulate earlier, more rapid, and
more substantial new bone formation than DFDBA in a monkey jaw defect model.

Table1. New bone formation following implantation

chamber 1 month 2 months 3 months
FDBA 163.3 80.9 213.7 103.0 443.5 60.8
DFDBA 7.7 0.6 26.8 33.1 217.3 111.1
Empty 92.0 130.1 55.7 38.6 142.7 107.7

Table 2. Amount of original graft material present

chamber 1 month 2 months 3 months
FDBA 219.5 35.5 240.7 32.3 57.0 15.6
DFDBA 297.5 73.3 237.6 106.6 170.3 57.7
Villaca J, Rodriguez D, Novaes A, Taba M et al. Root trunk concavities as a risk
factor for regenerative procedures of class II furcation lesions in humans. J
Periodontol 2004: 75; 1493-99. (17 Refs)

Purpose: To evaluated clinically the effect of root trunk concavities on the
regeneration of class II furcation lesions in humans and to determine a modification
in membrane design could improve the results

Materials and Methods: A total of 10 patients with chronic periodontal disease
were selected for this study. The criteria for selection were as follows:
1. At least 2 mandibular molars with class II furcation involvement (clinically
and radiographically determined)
2. No remarkable medical history
3. Non-smokers
4. No systemic antibiotic or chemotherapeutic agent in the previous 6-months
Full mouth SRP was performed and after 4 weeks baseline evaluation was performed
with a computerized probe at three sites per tooth (mesial, central and distal
buccally). Baseline and 12 months evaluations included the following clinical
parameters: PD, CAL, intravertical measurements of vertical (VD) and horizontal
defects depths (HD)
Intrasulcular measurements were performed by the reflection of a mucoperiostial,
open flap debridement plus root condition using EDTA 24% for 2 min and then the
vertical component was recorded using an acrylic stent at the presurgical midline
reference points. Vertical measurements were obtained from the base of the stent to
the bottom of the defect. The horizontal depth of the furcation defect was measured
from a line tangential to the buccal root surfaces extending horizontally to the
deepest portion of the defect. After measurements were recorded sites were assigned
randomly for treatment with ePTFE membrane or the modified membrane (MM).
The membranes were modified by removing the collars from the unused membranes,
cutting into 2 mm segments and then suturing the segments to the collar of a normal
membrane. The membranes were trimmed to cover the lesions and extended to the
adjacent bone between 2-3mm apically and laterally. They were then placed in
position 2-3mm below to the CEJ and secure with ePTFE sutures. Flaps were
coronally positioned. Amoxicilin plus clavulanic acid was prescribed. Sutures were
removed at 2 weeks after procedures and all membranes remained in placed for 6
months. During the 12 months control program was performed. Mann- Whitney test
was used for statistical analysis.

Findings and Conclusions:
Both MM and NM showed significant PD reduction at 1 year. MM from 2.93+-
1.35mm to 1.95mm and Nm from 3.27mm to 2.46mm. Percentage of PD reduction
was 33.4%+-28% for MM and 24.7%+-20.4% for NM
CAL: from the MM reduction was from 9.7 to 9.4mm and for the NM from 10.2 to
10.5mm
VD: For the MM was from 8.9 to 6.7 mm and NM from 9.2 to 7.7 mm
HD: For the MM reduction was 4.0 to 2.2mm and for NM from 4.1 to 3.1mm
The characteristics and anatomy of the root trunks influence negatively the results of
GTR because the adequate adaptation of the membranes when placed 2-3mm
apically to the CEJ does not occur allowing the apical migration of the J E and thus
impeding the regenerative procedure. The modified membrane resulted in greater
horizontal defect resolution of class II furcation defects. The collars of the
membranes should be modified to improve results when root concavities are present.

Tsitoura E., Tucker R, Suvan J, et al. Baseline Radiographic defect angle of the
intrabony defect as prognostic indicator in regenerative periodontal surgery with
enamel matrix derivative. J Clin Periodontol 2004; 31: 643-7.

Purpose: To investigate whether an association exists between baseline radiographic
defect angle and treatment outcome when enamel matrix derivative (EMD) is used in
periodontal regenerative surgery.

Materials and Methods: The radiographs obtained for this study, to measure the
intrabony defect angles, were originally taken as part of a multicenter clinical trial,
using a population of 166 patients, which evaluated the clinical outcomes following
treatment of intrabony defects with papilla preservation flap surgery with or without
application of EMD. At study baseline and 1 year after treatment, the following
parameters were evaluated: full mouth plaque score (FMPS), full mouth bleeding
score (FMBS), probing pocket depth (PPD), recession of gingival margin (REC) and
clinical attachment level (CAL). Routine diagnostic radiographs were taken with a
long cone paralleling technique. A calibration exercise was carried out to obtain an
acceptable intra and interexaminer reproducibility for probing pocket depth,
recession of the gingival margin and evaluation of the defect. The radiographic angle
of intrabony component of the defect was measured with the assistance of DSR,
which is a customized software program.

Findings and Conclusions: The baseline evaluations show a mean PPD of 8.1 +
1.6mm. Mean CAL was 9.6 +2.2mm. The mean distance from the CEJ to the bottom
of the defect was 10.3 +2.5mm, with an intrabony component of 5.7 +2mm. The
clinical outcome after one year past the therapy showed that the mean CAL gain was
3.2 +1.6 mm. The mean decrease in PPD was 4.1 +1.6mm. A highly significant
correlation was observed between the radiographic defect angle and the baseline
PPD, the depth of the intrabony component of the defect as well as the distance
between the CEJ and the bottom defect. The probability of obtaining CAL gain >
3mm was 2.46 times higher when the radiographic defect angle was <22 degrees
than when it was >36 degrees. There was a statistically highly significant center
effect in the CAL gain probability analysis. The study showed that there was a
significant association between baseline radiographic defect angle and CAL gain at 1
year. The observed increased odds ratio of obtaining CAL gain of >4mm after
regenerative surgery with EMD is used in narrow (<22 degrees) intrabony defects,
suggests that the baseline radiographic defect angle might be used as prognostic
indicator of treatment outcome.